REVIEW
Nutrition in the Acute Phase
of Critical Illness
N Engl J Med 2014;370:1227-36.
Michael P. Casaer, M.D., Ph.D., and Greet Van den Berghe, M.D., Ph.D.
호흡기 내과 / F 임효석
Introduction
•
Critically ill patients
- commonly anorexia
- unable to feed by mouth
•
Inappropriate nutrition
 lean-tissue wasting  adverse outcomes
prolonged need for mechanical ventilation and rehabilitation
prolonged duration of stay in the ICU
Nutritional support
언제 ? (Early versus Late)
어떻게 ? (Enteral versus Parenteral)
얼마만큼 ?
Enteral nutrition
•
Timing of Initiation
suggest enteral nutrition early during critical illness
1) integrity of the gut mucosa  lower risk of infection
2) a better outcome in early enteral feeding group (MV 시작 48시간 이내 feeding)
Effects of Early Enteral Feeding on the Outcome of Critically Ill Mechanically Ventilated Medical Patients
Vasken Artinian et al. Chest. 2006;129(4):960-967
Enteral nutrition
•
Estimation of Energy Requirements
- charateristics of the patients before the onset of illness (키, 몸무게, 나이 등)
초기 : 18kcal/kg/day
1주일 째 : 25-30 kcal/kg/day (체중 증가가 필요한 경우 35 kcal/kg/day)
BMI 가 30 이상의 경우에는 감량
(대한중환자의학회 중환자 영양지원 지침)
- daily assessment per day in ICU (Indirect calorimetry)
: measurements of oxygen consumption and
carbon dioxide production
Enteral nutrition
•
Estimation of Energy Requirements
Tight Calorie Control Study (TICACOS)
- Patients who were undergoing mechanical ventilation in an ICU
- indirect calorimetry group versus control group
(daily reassessed)
(calculated energy target : 25 kcal/kg/day)
 more nutrition in indirect calorimetry group
indirect calorimetry
control
hospital mortality
reduced
Ref.
infections
increasd
Ref.
length of
stay in the ICU
increasd
Ref.
Enteral nutrition
Effect of Evidence-Based Feeding Guidelines on Mortality of Critically Ill Adults
Gordon S. Doig et al. JAMA. 2008;300(23):2731-2741
Enteral nutrition
Effect of Evidence-Based Feeding Guidelines on Mortality of Critically Ill Adults
Gordon S. Doig et al. JAMA. 2008;300(23):2731-2741
1.
2.
3.
4.
Earlier initiation of feeding
Increased attainment of caloric goals
No additional benefit regarding mortality
Additional benefit regarding LOS in the ICU or hospital ?
Enteral nutrition
•
Hypocaloric feeding, or permissive underfeeding
1. Shorter duration of mechanical ventilation
2. Improved mortality
-
preserving intestinal epithelium
stimulating secretion of brush border enzymes
enhancing immune function
preserving epithelial tight cell junction
preventing bacterial translocation
Enteral nutrition
Initial Trophic vs Full Enteral Feeding in Patients With Acute Lung Injury
The EDEN randomized trial JAMA. 2012;307(8):795-803
Enteral nutrition
•
Gastric Residual Volume
- gastric emptying is often slow in ICU patients
- regurgitation of gastric content
 aspiration pneumonia
 discontinuation of enteral feeding
The Gastric Residual Volume during Enteral Nutrition in ICU Patients (REGANE) trial
: gastric residual volumes up to 500 ml could be safely tolerated
NUTRIREA 1 trial
: the omission of the measurement of gastric residual volumes did not increase the incidence
of aspiration or related complications
Enteral nutrition
JAMA. 2013;309(3):249-256
Enteral nutrition
•
Prokinetic agents : improve gastric emptying
- metoclopramide
- erythromycin
 clinical outcome에 영향을 주지는 못함.
•
Prokinetic-resistant impaired gastric emptying
- bypass the stomach
- deliver nutrition directly beyond the pylorus
Parenteral Feeding
Parenteral feeding과 연관된 합병증
1. 카테터 관련 합병증
- 혈전생성 가능성 증가
- 카테터 감염 또는 패혈증
- 기흉
2. 대사적 합병증
- AST/ALT 증가
- 재급식 증후군
- 혈당 조절 장애
- 전해질 이상
- 담즙 울체 (cholestasis)
- 장점막의 위축, 이로 인해 박테리아나 내독소에 대한 투과성 증가  간장애, 패혈증
(대한중환자의학회 중환자 영양지원 지침)
Parenteral Feeding
Q: parenteral nutrition should be initiated in ICU patients?
and, if so, when?
European guidelines
- within 48 hours after admission to the ICU
American and Canadian guidelines
- hypocaloric enteral nutrition for 1 week in well-nourished patients
a. liver-function abnormalities
b. hyperglycemia
c. hypertriglyceridemia
d. infections
Parenteral Feeding
Early versus Late Parenteral Nutrition in Critically Ill Adults
EPaNIC trial N Engl J Med 2011;365:506-17.
Parenteral Feeding
Lancet 2013; 381: 385–93
Parenteral Feeding
JAMA. 2013;309(20):2130-2138
Parenteral Feeding
JAMA. 2013;309(20):2130-2138
Selection on Macronutrients
•
Amino Acids
Effects of exogenous protein : controversial
Glutamine
- nonessential free amino acid
- skeletal muscle에서 합성
- low glutamine level
a poor outcome in critical illness과 연관
consequence of muscle wasting 의 반영
immune cells, enterocytes, hepatocytes 등에 필요한 glutamine 공급 부족
- routine glutamine supplementation : controversial
•
Lipid
OMEGA study : no benefit with the enteral administration of n–3 fatty acids plus antioxidant
supplements
Selection on Micronutrients
•
Trace elements, vitamins, electrolytes
Refeeding syndrome
-
장기간 금식으로 micronutrient가 결핍된 상태에서 식이를 다시 시작할 때 발생
thiamine, potassium, phosphate 의 결핍
acute phase of critical illness 기간에는 full enteral intake가 안될 시 IV micronutients 공급
식이를 시작하기 전 위의 인자들을 교정하는 것이 예방법
Conclusions
Take home messages
•
At ICU admission, the nutritional target was set for all admitted patients
25 kcal per kg of ideal bodyweight a day for women
30 kcal per kg of ideal bodyweight a day for men
장관영양지원 금기 대상이 아니면 가급적 조기(48시간 내)에 enteral feeding을 시작하려고 노력
초기에는 상기 목표 칼로리의 50-65% 를 공급하고 1주일 째에는 100% 도달하도록 노력
영양 상태가 양호하다면 첫 48시간 이내에 parenteral feeding을 시작할 필요는 없다.
영양 상태가 불량하고, 장관 영양 지원을 1주일 이내 시작하지 못할 것으로 판단이 되면 정맥
영양 지원을 고려 한다.